Evaluating the Connections Between Primary Care Practice and Clinical Laboratory Testing: A Review of the Literature and Call for Laboratory Involvement in the Solutions

Abstract

N Context.-Growing evidence has demonstrated a high frequency of quality gaps in laboratory medicine, with recent studies estimating that 15% to 54% of primary care medical errors reported by primary care physicians and staff are related to the testing process. However, there is lack of evidencebased performance metrics in the preanalytic and postanalytic phases of the testing pathway for primary care practices.Objective.-To use results of the literature review to assist in the development of quality indicators that could improve preanalytic and postanalytic processes in primary care-based laboratory medicine.Data Sources.-Literature in Ovid/MEDLINE from 2001 through 2011 was searched as a primary source of information. Ninety-five peer-reviewed and non-peer-reviewed publications were retrieved following title and abstract review and 10 articles were reviewed in their entirety by the authors. A systematic review of the literature was conducted regarding the connections between clinical laboratories and primary care offices and the resulting errors. Root causes of errors were categorized into 7 major themes: process failures, delays, communication gaps, errors in judgment and cognition, influence of minorities/ language, practice culture, and lack of patient centeredness. Selected articles were evaluated for evidence quality using the Systematic Evidence Review and Evaluation Methods for Quality Improvement grading scale developed by the Centers for Disease Control and Prevention.Conclusions.-The focused literature review documented 7 key error themes in the laboratory medicine/primary care testing process. Performance metrics related to these themes are proposed that deserve future study for evidence-based improvement.(Arch Pathol Lab Med. 2013;137:120-125; doi: 10.5858/ arpa.2011-0555-RA) P rimary care physicians order many laboratory tests for their patients. Recent estimates are that the average family physician and general internist order laboratory testing in 29% and 38% of patient encounters, respectively. 1In addition to high laboratory test volume, there is growing evidence of the high frequency of quality gaps in primary care laboratory medicine, with recent studies estimating that 15% to 54% of primary care medical errors reported by primary care physicians and their staff are related to the testing process.1 Because of the volume of laboratory testing and high frequency of medical errors due to laboratory testing, there is a need for improved quality in the area. The Institute of Medicine (IOM) provides a framework for understanding the quality of health care by defining it as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.2 The IOM further classifies quality into 6 domains: safety, timeliness, effectiveness, efficiency, equity, and patient centeredness 3,4 (Figure 1). In laboratory medicine, multiple studies have shown that the majority of errors or gaps in quality take place...

Performance criteria of the post-analytical phase

“…A recent review showed that the quality gaps in laboratory medicine, as perceived in primary care, include not only delays but communication gaps, errors in judgement and cognition and a lack of patient centeredness [92].…”

Laboratory Medicine Handoff Gaps Experienced by Primary Care Practices: A Report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP)

“…4 The questionnaire was modeled after an instrument developed by the American Academy of Family Physicians National Research Network (Test Processing Survey Questionnaire). 5 All questionnaires were produced using the Snap Survey software program (Snap Surveys Ltd, Bristol, UK) that allows completed surveys to be scanned for efficient data entry, review, and analysis.…”

“…3 Studies examining the frequency and causes of laboratory errors in primary care indicate that ambulatory care practice characteristics affect error detection and frequency. 4 For example, practices lacking a specific system to manage laboratory test orders are twice as likely to report errors as practices with a system. 5 As many as half of physician-reported errors have been related to the laboratory testing process.…”

Launching a Laboratory Testing Process Quality Improvement Toolkit: From the Shared Networks of Colorado Ambulatory Practices and Partners (SNOCAP)

“…3 Critical handoffs occur between the clinician and laboratory, and while failures in this space rarely have catastrophic consequences, patients may more commonly experience emotional distress or delayed diagnosis and practices may suffer financial loss. 4 With the roll out of meaningful use standards by the Centers for Medicare and Medicaid Services and provisions of the Affordable Care Act that are moving the health care system from a fee-for-service model to a pay-for-performance model, there is significant incentive for practices to improve the quality of their laboratory testing processes.…”

“…Identified root causes of errors fell into 7 major themes: process failures, delays, communication gaps, errors in judgment and cognition, influence of minorities/language, practice culture, and lack of patient centeredness. 3 In phase 2 of the project, the team administered a survey to assess perceptions of laboratory hand-off gaps in primary care practices in Colorado to better understand the perceived gaps in these processes and as a precursor to the initiation of process improvement activities. Identified commonalities in test tracking and patient notification challenges warranted the development of a laboratory testing toolkit to facilitate QI in pre-and postanalytic testing processes.…”